1. Motivational Interviewing Steps and Core skills

2. Learning Objectives  At the end of the session, you will be able to— 1.Identify MI basic steps. 2.Identify MI core skills. 3.Demonstrate and practice MI using core skills.

3. Motivational Interviewing Steps

4. Four Steps of the MI Process 1.Engage 2.Focus 3.Evoke 4.Plan

5. Four Steps of the MI Process (continued)  Engage  Express empathy  Ask questions  Use affirmations  Support autonomy

6. Four Steps of the MI Process (continued)  Focus  Reflecting  Summarizing  Developing discrepancies

7. Four Steps of the MI Process (continued) Evoke  Motivation  Concerns

8. Four Steps of the MI Process (continued) Plan  Raise the subject  Support self-efficacy  Address elements of change

9. Video Demonstration

10. Motivational Interviewing Core skills

11. Core MI  Open-ended questions  Affirmations  Reflections  Summaries

12. Open-Ended Questions Using open-ended questions—  Enables the patient to convey more information  Encourages engagement  Opens the door for exploration

13. Open-Ended Questions (continued) What are open-ended questions?  Gather broad descriptive information  Require more of a response than a simple yes/no or fill in the blank  Often start with words such as— – “How…” – “What…” – “Tell me about…”  Usually go from general to specific

14. Open-Ended Questions (continued)  Why open-ended questions? – Avoid the question- answer trap Puts patient in a passive role No opportunity for patient to explore ambivalence

15. Open-Ended Questions (continued)  Why open-ended questions? – Opportunity to explore ambivalence

16. Closed-Ended Questions Present Conversational Dead Ends Closed-ended questions typically—  Are for gathering very specific information  Tend to solicit yes-or-no answers  Convey impression that the agenda is not focused on the patient

17. Exercise Turning closed-ended question into an open-ended one. Do you feel depressed or anxious?

18. Affirmations What is an affirmation?  Compliments or statements of appreciation and understanding – Praise positive behaviors – Support the person as they describe difficult situations

19. Affirmations (continued) Why affirm?  Support and promote self-efficacy, prevent discouragement  Build rapport  Reinforce open exploration (patient talk) Caveat  Must be done sincerely

20. Affirmations May Include:  Commenting positively on an attribute – You are determined to get your health back.  A statement of appreciation – I appreciate your efforts despite the discomfort you’re in.  A compliment – Thank you for all your hard work today.

21. Reflective Listening Reflective listening is one of the hardest skills to learn. “Reflective listening is a way of checking rather than assuming that you know what is meant.” (Miller and Rollnick, 2002)

22. Reflective Listening (continued)  Involves listening and understanding the meaning of what the patient says  Accurate empathy is a predictor of behavior change

23. Reflective Listening (continued)  Why listen reflectively? – Demonstrates that you have accurately heard and understood the patient – Strengthens the empathic relationship

24. Reflective Listening (continued)  Why listen reflectively? – Encourages further exploration of problems and feelings  Avoid the premature-focus trap – Can be used strategically to facilitate change

25. Levels of Reflection  Simple Reflection—stays close – Repeating – Rephrasing (substitutes synonyms)  Example  Patient: I hear what you are saying about my drinking, but I don’t think it’s such a big deal.  Clinician: So, at this moment you are not too concerned about your drinking.

26. Levels of Reflection (continued)  Complex Reflection—makes a guess – Paraphrasing—major restatement, infers meaning, “continuing the paragraph”  Examples Patient: “Who are you to be giving me advice? What do you know about drugs? You’ve probably never even smoked a joint! Clinician: “It’s hard to imagine how I could possibly understand.” *** Patient: “I just don’t want to take pills. I ought to be able to handle this on my own.” Clinician: “You don’t want to rely on a drug. It seems to you like a crutch.”

27. Levels of Reflection (continued)  Complex Reflection – Reflection of feeling—deepest  Example Patient: My wife decided not to come today. She says this is my problem, and I need to solve it or find a new wife. After all these years of my using around her, now she wants immediate change and doesn’t want to help me! Clinician: Her choosing not to attend today’s meeting was a big disappointment for you.

28. Double-Sided Reflections A double-sided reflection attempts to reflect back both sides of the ambivalence the patient experiences. Patient: But I can't quit smoking. I mean, all my friends smoke! Clinician: You can't imagine how you could not smoke with your friends, and at the same time you're worried about how it's affecting you. Patient: Yes. I guess I have mixed feelings.

29. Summaries  Periodically summarize what has occurred in the counseling session.  Summary usages – Begin a session – End a session – Transition

30. Summaries (continued) Strategic summary—select what information should be included and what can be minimized or left out. Additional information can also be incorporated into summaries—for example, past conversations, assessment results, collateral reports, etc.

31. Summaries (continued)  Examples – “So, let me see if I’ve got this right…” – “So, you’re saying… is that correct” – “Make sure I’m understanding exactly what you’ve been trying to tell me…”  Double sided reflections are often highly effective as summaries to illustrate ambivalence.

32. Learning Exercise

33. Exercise OARS in practice

34. Conclusion  In this session, you have learned the steps and core motivational interviewing skills.  In the next session, you will use these core skills plus selected tools that help patients better understand their competing priorities and ambivalence to change—to resolve their ambivalence and increase motivation for behavior change.